Tuberculosis spreading through surgical procedures

Several days after Jaya Rani Das underwent a caesarean section to give birth, the surgical wound had still not healed. Physicians prescribed one medicine after another, but the wound did not improve. Then one day, tests revealed tuberculosis at the wound site. The wound was not healing because of the that.

Later, it emerged that Jaya Rani was not the only one affected, at least 11 other women who had undergone surgery at the same hospital had also contracted the disease. The health department has launched an investigation into the incident.

The incident took place at Al-Madina Lab and Hospital in Faridpur upazila of Pabna. Around 120 women underwent surgical deliveries at the hospital in May and June. Of them, 11 were found to have contracted tuberculosis at the hospital. In addition, tuberculosis was detected in the wound of a man who had undergone gallbladder surgery.

TB specialists, however, say infections during surgical procedures are not a new phenomenon. But they consider the scale of the incident in Pabna to be significant.

Jaya Rani Das lives in the Thanapara area of the upazila. She is around 20 years old. She was admitted to Al-Madina Hospital on 22 May and underwent surgery to deliver her baby that day. She returned home with her baby on 24 May.

On 29 May, she went back to the hospital to have her stitches removed and the wound dressed before returning home. She took the prescribed medicines and followed the physicians’ instructions. But even after about two weeks, the wound on her abdomen had not healed.

The Prothom Alo correspondent spoke to Jaya Rani and her parents on 30 August. They said the entire surgical wound was not healing. Pus accumulated and fluid continued to ooze from it. Jaya went to the hospital several times and physicians prescribed medicines, but the wound did not heal.

At one point, a tissue sample from the wound was sent to a private hospital in Rajshahi. Jaya Rani was also sent to Rajshahi. Tests on the sample in the final week of July detected tuberculosis at the wound site. Jaya was then quickly provided with anti-tuberculosis medication through the National Tuberculosis Control Programme. According to the records, Jaya Rani Das began taking TB medication on 25 July.

Describing the incident as alarming, Faridpur Upazila Health and Family Planning Officer Md Rashedul Hasan told Prothom Alo, 12 people who had undergone surgery at the hospital in May and June were later diagnosed with tuberculosis. One of them had undergone gallbladder surgery, while the other 11 had undergone surgery to deliver their babies. He added that identifying the source of tuberculosis is difficult and time-consuming.

The upazila health and family planning officer said they had taken three measures. Surgical procedures at Al-Madina Hospital had been suspended, a three-member committee has been formed to investigate the incident, and a letter had been sent to the Institute of Epidemiology, Disease Control and Research (IEDCR), requesting an investigation into the cause of the infections.

District Civil Surgeon Md Abul Kalam Azad told Prothom Alo that some of the hospital’s equipment was relatively old. Surgical procedures had been suspended for the time being. The district civil surgeon’s office had informed the National Tuberculosis Control Programme about the incident and requested a proper investigation.

A team comprising National Tuberculosis Control Programme Director Mohammad Shahriar Sazzad, officials from IEDCR and the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) arrived in Pabna on Saturday evening.

Tuberculosis is primarily a disease of the lungs. As it affects the lungs, it is commonly associated with coughing. Medical science says tuberculosis can also affect several other organs of the body besides the lungs. This is known as extrapulmonary tuberculosis.

Tuberculosis occurring at a wound site is also a form of extrapulmonary TB. Treatment for this type of tuberculosis also requires daily, regular intake of anti-tuberculosis medicines. The government provides these medicines free of charge. Jaya Rani Das is also taking medication provided through the government programme

Al-Madina Hospital is located at the Muktijoddha Complex in the Tetultala area of Faridpur upazila. The hospital occupies the ground and first floors of the complex building. On 30 August, this correspondent spoke to the hospital’s managing director, Md Masud Rana, operating theatre (OT) in-charge Md Ariful Islam, and several other officials and employees.

The hospital has 10 beds. According to the Directorate General of Health Services, a 10-bed hospital must have at least three permanent physicians, six nurses, a labour room, an operating theatre, an 800-square-foot ward and an emergency room, among other facilities. The hospital has been operating since 2020 without fully meeting these requirements.

During a visit to the hospital it was found that there was no room measuring 800 square feet. The operating theatre was quite clean and appeared to have been washed and cleaned recently. Two old autoclave machines had been cleaned and kept there. A new autoclave machine had been brought in a day or two earlier and had not yet been used. Next to the operating theatre was a room for normal deliveries, but no bed was seen there.

Hospital managing director Md Masud Rana said two to three deliveries are performed by caesarean section at the hospital every day. There are 60 to 70 such operations a month. Caesarean deliveries are the hospital’s main source of income. Some normal deliveries are also performed, he said.

Obstetricians say every facility must follow labour room protocols or delivery-room guidelines for each delivery. The hospital’s managing director and OT in-charge could not show this correspondent any such guidelines, nor did they know that such guidelines were required. Both claimed that the equipment is sterilised after every operation. However, they could not provide any evidence to support this.

OT in-charge Md Ariful Islam said there were two possible sources of the tuberculosis infection: a patient or the operating theatre. Managing director Md Masud Rana said, “This is a very serious incident for us. It will be difficult to avoid responsibility for the infection. We also need to find out how this happened.”

Cases of tuberculosis spreading due to operating theatres and surgical equipment not being properly sterilised have also been reported. In February this year, several women contracted tuberculosis during caesarean deliveries at Modern Diagnostic Centre and Clinic in Bhedarganj upazila of Shariatpur district. IEDCR and the National Tuberculosis Control Programme jointly investigated the incident in June and confirmed the incident.

Bhedarganj Upazila Health and Family Planning Officer Abu Naim Md Iftekharul Islam told Prothom Alo on Saturday that tuberculosis had been detected in 51 people who had undergone surgery at the clinic. The clinic and its operating theatre have been closed since March. However, its diagnostic services remain operational.

Mohammad Shahriar Sazzad, director of the National Tuberculosis Control Programme, told Prothom Alo that they were aware of incidents in two upazilas in Pabna and Shariatpur. He said they were not aware of any such incidents elsewhere.

However, an official of a foreign organisation working with the National Tuberculosis Control Programme told Prothom Alo on Saturday that they had contacted four hospitals in four northern districts and learned that those hospitals were finding patients with tuberculosis at surgical wound sites on a fairly regular basis.

Senior obstetrics and gynaecology specialist Professor Rowshan Ara Begum said, “It is frightening to hear about these cases.” She told Prothom Alo, “We had previously heard about tuberculosis infections occurring during laparoscopy—surgery performed through small openings in the abdomen rather than by making a large incision. Now we are hearing that it is occurring during childbirth by surgery. The Directorate General of Health Services should take urgent action.”

According to the World Health Organization (WHO), Bangladesh is one of the countries in the world with a high prevalence of tuberculosis. Around 350,000 people in the country develop tuberculosis every year. Not everyone who contracts tuberculosis each year is diagnosed. Not everyone who is diagnosed receives treatment, and not everyone who receives treatment recovers. Around 44,000 people die from tuberculosis every year.

Tuberculosis specialists, obstetricians and gynaecologists, and health officials working at the field level who spoke to Prothom Alo expressed concern over the incidents in Pabna and Shariatpur. They all said the health authorities need to pay particular attention to the issue. One upazila health official said urgent measures need to be determined to address the matter. At the same time, it is also important to take steps to prevent fear from spreading among the public.

Renowned chest specialist Asif Mujtaba Mahmud told Prothom Alo, “Before use, it must be ensured that the hospital’s operating theatres and surgical equipment are properly disinfected in accordance with the prescribed procedures.”

(Sarwar Morshed, Pabna, contributed to this report.)